Revised December 20, 2005

Objective 4.1
90% of health systems will have an organizational program, with appropriate pharmacy involvement, to achieve significant annual, documented improvement in the safety of all steps in medication use.

Baseline 60.5% (95% CI, 55.4–65.3%)

Crosswalk Resources

1. JCAHO (MM.8.1)
2. Supporting Literature - References 1, 58 

Objective 4.2
80% of pharmacies in health systems will conduct an annual assessment of the processes used throughout the health system for compounding sterile medications, consistent with established standards and best practices.

Baseline 35.7% (95% CI, 31.1–40.6%)

Crosswalk Resources

1. JCAHO (MM.4.20)
2. USP International Standard 
3. ISO 9000
4. Supporting Literature - References 1, 59, 60  

Objective 4.3
80% of hospitals have at least 95% of routine medication orders* reviewed for appropriateness by a pharmacist before administration of the first dose.

Baseline 45.7% (95%CI, 41.3-49.9%)

(*Not including doses required in the context of emergencies or immediate procedures such as surgeries, labor and delivery, cardiac catheterization, etc.)

Crosswalk Resources

1. JCAHO (MM.4.)
2. Supporting Literature - Reference 11 

Objective 4.4
90% of hospital pharmacies will participate in ensuring that patients receiving antibiotics as prophylaxis for surgical infections will have their prophylactic antibiotic therapy discontinued within 24 hours after the surgery end time.

Baseline 31.0% (95% CI, 26.6–35.8%)

Crosswalk Resources

1. Core Measures
2. Surgical Infection Project
3. Surgical Care Improvement Project
4. Supporting Literature - References 1, 61-64 

Objective 4.5
85% of pharmacy technicians in health systems will be certified by the Pharmacy Technician Certification Board.

Baseline 2004: 60.5% (95% CI, 56.1–64.9%)     2005: 53.9% (95% CI, 49.8-58.0%)

Crosswalk Resources

1. NABP
2. Pharmacy Technician Certification Board
3. Supporting Literature - References 1, 11